Diabetes or high blood sugar. Kidney disease, stones, blood in HAS THE PATIENT BEEN HOSPITALIZED WITHIN THE LAST THREE YEARS DUE TO DIABETES COMPLICATIONS? …

PHYSICIAN RETURN FORM TO:
A Public Service Agency

Medical information is CONFIDENTIAL under Section 18085 CVC

DRIVER MEDICAL EVALUATION

INSTRUCTIONS TO THE DRIVER: Please take this form to the doctor most familiar with your health history and current medical condition Before giving this form to your doctor, complete name/address, complete and sign the HEALTH HISTORY and the MEDICAL INFORMATION AUTHORIZATION sections on this page INSTRUCTIONS TO THE DOCTOR: Please complete the section, DOCTORS MEDICAL EVALUATION, on pages 2 through 5 The Department of Motor Vehicles records indicate your patient may have a condition that could affect the safe operation of a motor vehicle In this case, the department is concerned about the following conditions:
TO BE COMPLETED BY DMV HEARING OFFICER RETURN BY:

NAME LAST, FIRST, MIDDLE

DRIVER LICENSE NO

BIRTH DATE

FIELD FILE

STREET ADDRESS

CITY

ZIP

PATIENTS DAYTIME OR HOME PHONE NO

PATIENT MUST COMPLETE HEALTH HISTORY BELOW Please explain any YES answers
YES NO YES NO

Head, neck, spinal injury, disorders or illnesses Seizure, convulsions, or epilepsy Dizziness, fainting, or frequent headaches Eye problem except corrective lenses
Cardiovascular heart or blood vessel disease Heart attack, stroke, or paralysis Lung disease include tuberculosis, asthma or emphysema Nervous stomach, ulcer, or digestive problems Diabetes or high blood sugar

Kidney disease, stones, blood in urine, or dialysis Muscular disease Any permanent impairment Nervous or psychiatric disorder Regular or frequent alcohol use Problems with the use of alcohol or drugs Suffering from any other disease Any major illness, injury, or operations in last 5 years Currently taking medications

EXPLANATION: Include onset date, diagnosis, medication, doctors name and address and any current condition or limitation Attach additional sheet, if needed

I certify under the penalty of perjury, under the laws of the State of California, that I have provided true and complete information concerning my health
DATE DRIVERS SIGNATURE

DRIVERS ADVISORY STATEMENT Medical information is required under the authority of Divisions 6 and 7 of the California Vehicle Code Failure to provide the information is cause for refusal to issue a license or to withdraw the driving privilege All records of the Department of Motor Vehicles, relating to the physical or mental
condition of any person, are confidential and not open to public inspection California Vehicle Code Section 18085 Information used in determining driving qualifications is available to you and/or your representative with your signed authorization The department has sole responsibility for any decision regarding your driving qualifications and licensure The department will also consider non-medical factors in reaching a decision MEDICAL INFORMATION AUTHORIZATION Valid for three years
DOCTOR, HOSPITAL, OR MEDICAL FACILITY NAME AND ADDRESS

DATE

MEDICAL RECORD/PATIENT FILE NO

I hereby authorize my doctor or hospital to answer any questions from the Department of Motor Vehicles, or its employees, relating to my physical or mental condition, and/or drug and/or alcohol use, and to release any related information or records to the Department of Motor Vehicles or its employees Any expense involved is to be charged to me and not to the Department of Motor Vehicles I hereby authorize the Department of Motor Vehicles to receive any information relating to my physical or mental condition, and/or drug and/or alcohol use or abuse, and to use the same in determining whether I have the ability
to operate a motor vehicle safely NOTE: You may wish to make a copy of the completed Driver Medical Evaluation for your records
SIGNED DATE

WITNESS

DATE

DS 326 REV 11/2003 WWW

Page 1 of 5

DOCTORS MEDICAL EVALUATION INSTRUCTIONS TO THE DOCTOR: The Department of Motor Vehicles records indicate your patient may have a condition that could affect the safe operation of a motor vehicle See Instructions to the Doctor, page 1 for the specific medical conditions that is a concern to the department With your assistance, the department hopes to resolve the matter with a minimum of inconvenience to all concerned The Health History and Medical Information Authorization sections on page 1 must be completed and signed by the patient before you complete this Driver Medical Evaluation form Your experience and knowledge of the patients condition, results of medical examinations and treatment plans, will be of great value in assisting the department to determine a proper licensing decision PLEASE ANSWER ALL QUESTIONS on this form that are applicable to your patients conditions You may furnish a narrative report if you prefer, but please include all information pertinent to your patient The
department has sole responsibility for any decision regarding the patients driving qualifications and licensure The department will also consider non-medical factors in reaching a decision VISION
VISUAL ACUITY without bioptic telescope Without Lenses With Present Lenses BOTH EYES 20/ 20/ 20/ 20/ RIgHT EYE 20/ 20/ LEFT EYE

ANY EYE INjURY OR DISEASE? LIST

IS FURTHER EYE ExAMINATION SUGGESTED?

Yes No TREATMENT BY OTHER DOCTORS
IS THIS PATIENT BEING TREATED FOR ANY CONDITION BY ANOTHER DOCTOR?

Yes

IF YES, PLEASE INDICATE NAME OF TREATING DOCTORS

CONDITION BEING TREATED

TREATMENT UNDER YOUR SUPERVISION
DIAGNOSIS If the dIagnosIs Is a dIsorder characterIzed by lapses of conscIousness, dementIa, or dIabetes, complete page 3 or 4

DO YOU NEED TO SEE YOUR PATIENT AT REGULAR INTERVALS? IF YES, HOW OFTEN?

Yes
PROGNOSIS

IS THE CONDITION

Improving
MANIFESTATIONS:

Stable
SYMPTOMS

Worsening or deteriorating

Subject to change

IF MULTIPLE CONDITIONS, PLEASE DESCRIBE STATUS AND PROGNOSIS IN COMMENTS BELOW

PRESENT

PAST

MAY CONDITION IMPAIR VISION?

Yes
HOW LONG HAS THIS PERSON BEEN YOUR PATIENT? DATE OF LAST EXAMINATION

IS YOUR PATIENT UNDER A CONTROLLED MEDICAL
PROGRAM?

HOW LONG HAS CONTROL BEEN MAINTAINED?

Yes Yes

No
IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL CONDITION?

IS THE PATIENT ADHERING TO THE MEDICAL REGIMEN? IF NO, PLEASE EXPLAIN:

Yes

LIST THE MEDICATIONS PRESCRIBED PLEASE INCLUDE DOSAGE AND FREQUENCY OF USE

WHEN WAS THE LAST MEDICATION CHANGE MADE?

WOULD THE SIDE EFFECTS FROM THE PRESCRIBED MEDICATIONS INTERFERE WITH THE SAFE OPERATION OF A MOTOR VEHICLE?

Yes Yes

No No

If yes, please describe: Uncertain

IN YOUR OPINION, DOES YOUR PATIENTS MEDICAL CONDITION AFFECT SAFE DRIVING?

HAVE YOU ADVISED AGAINST DRIVING?

DOCTORS COMMENTS:

Page 2 of 5

DS 326 REV 11/2003 WWW

LEVELS OF FUNCTIONAL IMPAIRMENTS Functional impairments that may affect safe driving ability Please check where applicable
MILD MODERATE SEVERE

Visual neglect Left side Right side Loss of upper extremity motor control Left side Right side Loss of lower extremity motor control Left side Right side
WOULD ADAPTIVE DEVICES AID YOUR PATIENT IN COMPENSATING FOR HIS/HER DISABILITY?

Yes

Uncertain

IF YES, PLEASE DESCRIBE

WOULD YOU RECOMMEND A DRIVING TEST BE GIVEN BY DMV?

Yes No Uncertain DEMENTIA OR COgNITIVE IMPAIRMENTS Alzheimers
Disease Other Dementia please describe the type of dementia below, eg, multi-infarct, metabolic, post-traumatic
HISTORY OF DISEASE, RESULTS OF TESTING, ETC

Using the definitions given below, please rate the severity of the following forms of cognitive impairments in this patient

DEFINITIONS: Mild: Judgment is relatively intact but work or social activities are significantly impaired Ability to safely operate Based on a motor vehicle may or may not be impaired DSM 111-R Moderate: Independent living is hazardous and some degree of supervision is necessary The individual is unable to cope with the environment and driving would be dangerous Severe: Activities of daily living are so impaired that continual supervision is required This person is incapable of driving a motor vehicle
NONE MILD

MODERAT

SEVERE

UNCERTAIN

Memory Loss Depression, secondary to dementia Diminished Judgment Impaired Attention Impaired Language Skills Impaired Visual Spatial Skills Impulsive Behavior Problem Solving Deficits Loss of Awareness of Disability OVERALL DEGREE OF IMPAIRMENT

DS 326 REV 11/2003 WWW

Page 3 of 5

LAPSE OF CONSCIOUSNESS DISORDER
PLEASE IDENTIFY THE LAPSE OF CONSCIOUSNESS
DISORDER BEING REPORTED type of seizure, nocturnal, isolated,DATES OF EPISODES IN THE PAST THREE YEARS syncope, blackouts, etc DATE OF ONSET, IF KNOWN DATE AND TIME OF LAST EPISODE

Please indicate the impairments identified below that are presently shown by your patient
YES NO UNCERTAIN

Sporadic loss of conscious awareness Loss of consciousness Impaired motor function EFFECTS AFTER EPISODE Confusion Diminished concentration Diminished judgment Memory loss If medication is taken to control seizures, are the serum levels recorded? Are the serum levels medically acceptable? DIABETES
PLEASE INDICATE THE TYPE OF DIABETES THIS PATIENT HAS DATE OF DIAGNOSIS

Type I

Type 2

Gestational Oral diabetes medication Insulin injections Insulin pump Other:

WHAT METHOD OF TREATMENT IS REQUIRED?

Controlled diet Yes Yes No No

HAS THIS PATIENT RECEIVED DIABETES EDUCATION FROM A HEALTH CARE TEAM?

DOES THIS PATIENT COMPLY WITH THE PRESCRIBED TREATMENT PLAN?

IF NO, PLEASE EXPLAIN

IS THE DIABETES CONTROLLED AT THIS TIME?

Yes

No
IF NO, PLEASE EXPLAIN

IF YES, HOW LONG HAS CONTROL BEEN MAINTAINED?

WHAT ARE THIS PATIENTS FASTING BLOOD GLUCOSE LEVELS?

AFTER HOW MANY HOURS OF
FASTING?

WITHIN THE LAST THREE YEARS, HAS THIS PATIENT EXPERIENCED

REASON FOR EPISODES eg, non-compliance w/regimen, change in condition, insulin unavailable, illness, etc

Hypoglycemic episodes?

Hyperglycemic episodes?
NONE MILD MODERATE SEVERE UNCERTAIN

Please indicate the complications manifested by the hypoglycemic or hyperglycemic episodes and rate the severity of each Abdominal pain Cognitive deficits Confusion Confusion or disorientation Incoordination Hypoglycemic unawareness Lack of stamina Loss of consciousness Stupor Visual changes Ketoacidosis Slowed reactions Seizures Weakness or fatigue Other _____________________________________________________________________________

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DS 326 REV 11/2003 WWW

DOES THIS PATIENT MANAGE HYPOGLYCEMIC OR HYPERGLYCEMIC EPISODES WITH OR WITHOUT HELP?

With

Without Kidney disease Nervous system disease Vascular disease

HAS THIS PATIENTS DIABETES CAUSED ANY OF THE FOLLOWING CHRONIC COMPLICATIONS?

Visual changes

PLEASE DESCRIBE THE EXTENT OF THE COMPLICATIONS

HAS THE PATIENT BEEN HOSPITALIZED WITHIN THE LAST THREE YEARS DUE TO DIABETES COMPLICATIONS?

WHAT COMPLICATIONS NECESSITATED HOSPITALIZATION?

Yes
Yes

No No